Over the past 10 years, the pharmaceutical industry has undergone a great deal of change in response to the numerous changes that have affected the health care industry. In response to these changes, the role of the pharmacist, as well as the entire practice of pharmacy, has changed.
As a result of the changes in the health care industry, the rate at which prescriptions are filled is continually on the rise. For instance, in the year 2001, there were more than 3 billion prescriptions filled according to the Schering Report XXIII: Pharmacists, Technicians and Technology: Serving the Patient (hereinafter “the Schering Report”). At the current rate, there is estimated to be over 4 billion prescriptions filled in the year 2004. As there are just over 50,000 pharmacies in the United States, including specialty programs such as nursing homes, institutional pharmacies and hospital pharmacies, the number of prescriptions filled each hour, by each pharmacy, is about 20 prescriptions.
In addition to the growing number of prescriptions, the number of unfilled pharmacist vacancies has nearly tripled in two years according to a report issued by the U.S. Department of Health and Human Services in December of 2000. Further, according to statistics provided by the National Association of Chain Drug Stores, there were approximately 6,503 open pharmacy positions as of January, 2002. Combining the number of unfilled pharmacist vacancies with the fact that the number of newly graduating pharmacists has declined in recent years, it is apparent that there is becoming a nationwide shortage of full-time pharmacists. Due to the increased demand and shortened supply of pharmacists, pharmacists may earn between about $80,000 to $100,000 annually.
In addition to paying higher salaries, pharmacy profit margins have also been decreasing. This decrease has resulted in the number of independent pharmacies (not affiliated with a chain store or mass merchandiser) to decline from about 30,503 in 1991 to 20,647 in 2001. Decreased profitability is attributable not only to increasing overhead costs, but also due to the overall business mix, including a larger percentage of third party prescriptions. Depending on the geographical location of the pharmacy, the percentage of third party prescriptions filled by the pharmacy (paid by an insurer or Medicaid/Medicare) ranged from 67 to 100 percent, with an average of 83 percent according to the National Association of Chain Drug Stores, Industry Statistics, 2002. Since the third party payer often allocates a maximum allowable cost per prescription, mandatory generic prescriptions, network discounts and prior authorizations, the amount of money the third party payor pays the pharmacy affects the profit margin of the pharmacy.
Concomitantly, the duties on each pharmacist are also increasing. For instance, the pharmacist not only takes the prescription order, commits the order to writing when called by a physician, consults with physicians and nurses on proper medication and doses, processes the prescription, checks for drug-drug interactions, obtains the proper medication, measures the quantity of the medication, fills the prescription, affixes a label to the prescription and completes the proper financial transaction to check the patient out of the pharmacy, the pharmacist also needs to counsel the patient. Patient counseling helps to ensure that the patient properly understands instructions on how to take the medication or use a pharmaceutical product such that that the medication or pharmaceutical product works optimally. In addition to filling prescriptions, the pharmacist also attends to a daily barrage of questions regarding over-the-counter medications and other pharmaceutical products that have increased in availability and complexity.
Most pharmacies provide services to Medicaid and Medicare patients and thus are subject to the Omnibus Reconciliation Act passed in 1990 (OBRA) which mandates that each Medicaid and Medicare patient receive the following information when getting a prescription: the name of the medication, the description of the medication, the dosage form, the dosage, how to administer the medication, the duration of the drug therapy, and how to handle missed doses. Additionally, almost every state requires that the patient be offered counseling on the prescription in which the above listed information is communicated by the pharmacist. Some states allow ancillary pharmacy staff to provide the counseling information, but other states require the pharmacist to personally counsel the patient.
Since most pharmacists are quite busy, pharmacies often use ancillary support staff to perform clerical duties and other functions. The number of support staff available to pharmacies is often limited by the states to a 2:1 or a 3:1 ratio of support staff to each pharmacist. Although the ancillary pharmacy staff perform a number functions to assist the pharmacist, patient counseling remains a duty relegated to the pharmacist. Although patients picking up refills typically refuse counseling at the point-of-sale (POS), according to the Schering report, pharmacists indicate that they counsel about 90-100% of patients that are picking up new prescriptions. Further complicating the ability of the pharmacist to counsel patients is the fact that compliance with managed health care and third party payor paperwork requirements adds more time to the prescription process. In a survey, about 75% of pharmacists and pharmacy technicians report spending about a third of their time dealing with paperwork, phone calls and other activities to resolve third-party and drug-benefit issues according to the Schering Report.
The pharmacist and the ancillary pharmacy staff are left with a small portion of time to counsel patients on the use of medications. Thus, the effectiveness of a drug's therapy may be jeopardized if the patient does not take the medication properly and the pharmacist does not have enough time to counsel the patient properly. For instance, it is estimated that between 30 and 50% of patients fail to comply with prescription instructions according to the article “A Pharmacist's Duty to Warn: Sound Economics, Effective Medicine and Consistent with Drug Regulation Theory” by Harit V. Trivedi, Harvard Law School, 1995.
Over the years, a number of innovations have been developed to reduce the pharmacist's workload, reduce costs and provide added value to customers in an effort to increase the efficiency of the practice of pharmacy. These innovations include centralized processing of third-party prescriptions, electronic prescribing, standardized pharmacy benefit cards, access to patient specific clinical information, in-pharmacy telephones that may be used by patients to call their doctor for refills, menu-driven interactive voice-response systems for refills and other information, and the ability to order refills on the internet. Electronic prescribing and standardized drug benefit cards focus on reducing the paperwork or administrative workload within the pharmacy. However, not all of these innovations are logistically practical and few of the innovations focus on reducing the counseling workload of the pharmacist. Furthermore, although in-pharmacy telephone interactive response systems and internet refills help ease the workload on the pharmacy, these innovations do not necessarily help provide the required counseling. Even though the innovations may increase the number of prescriptions filled each hour, the innovations do not help the pharmacist counsel the patient or explain pharmaceutical product information more effectively. Also, some of the innovations are still in the development stages and may be difficult or impractical to implement.